I.Uses and Disclosures for Treatment, Payment, and Health Care Operations

Imay use or disclose
your protected health information (PHI),
for treatment, payment, and health
care operations purposes with your consent.
To help clarify these terms, here are some definitions:

“PHI”
refers to information in your health record that could identify you.

“Treatment,
Payment and Health Care Operations”

Treatment
is when Iprovide,
coordinate, or manage your health care and other services related to
your health care. An example of treatment would be when Iconsult with another health care provider, such as your family
physician or another psychologist.

Payment
is when Iobtain
reimbursement for your healthcare.Examples
of payment are when Idisclose
your PHI to your health insurer to obtain reimbursement for your health
care or to determine eligibility or coverage.

Health
Care Operations are activities that relate to the performance and
operation of my practice.Examples
of health care operations are quality assessment and improvement
activities, business-related matters such as audits and administrative
services, and case management and care coordination.

“Disclosure”
applies to activities outside of my [office, clinic, practice group, etc.],
such as releasing, transferring, or providing access to information about
you to other parties.

II.Uses and Disclosures Requiring Authorization

Imay use or disclose PHI for purposes outside of treatment, payment, and
health care operations when your appropriate authorization is obtained. An “authorization”
is written permission above and beyond the general consent that permits only
specific disclosures.In those
instances when I am asked for information for purposes outside of treatment,
payment and health care operations, he will obtain an authorization from you
before releasing this information

You may revoke all
such authorizations at any time, provided each revocation is in writing. You may
not revoke an authorization to the extent that (1) I have relied on that
authorization; or (2) if the authorization was obtained as a condition of
obtaining insurance coverage, and the law provides the insurer the right to
contest the claim under the policy.

III.Uses and Disclosures with Neither Consent nor Authorization

I may use or
disclose PHI without your consent or authorization in the following
circumstances:

Child
Abuse: If I have reasonable cause, on the basis of my professional
judgment, to suspect abuse of children with whom he comes into contact in my
professional capacity, I am required by law to report this to the
Pennsylvania Department of Public Welfare.

Adult
and Domestic Abuse: If I have reasonable cause to believe that an older
adult is in need of protective services (regarding abuse, neglect,
exploitation or abandonment), I may report such to the local agency which
provides protective services.

Judicial
or Administrative Proceedings: If you are involved in a court proceeding
and a request is made about the professional services I provided you or the
records thereof, such information is privileged under state law, and I will
not release the information without your written consent, or a court order.
The privilege does not apply when you are being evaluated for a third party
or where the evaluation is court ordered. You will be informed in advance if
this is the case.

Serious
Threat to Health or Safety: If you express a serious threat, or intent
to kill or seriously injure an identified or readily identifiable person or
group of people, and I determine that you are likely to carry out the
threat, I must take reasonable measures to prevent harm.Reasonable measures may include directly advising the potential
victim of the threat or intent.

Worker’s
Compensation: If you file a worker’s compensation claim, I will be
required to file periodic reports with your employer which shall include,
where pertinent, history, diagnosis, treatment, and prognosis.

IV.Patient's Rights and Psychologist's Duties

Patients' Rights:

Right
to Request Restrictions–You have the right to request restrictions on certain uses and
disclosures of protected health information about you. However, I am not
required to agree to a restriction you request.

Right
to ReceiveConfidential
Communications by Alternative Means and at Alternative Locations –You have the right to request and receive confidential
communications of PHI by alternative means and at alternative locations.
(For example, you may not want a family member to know that you are seeing
me.Upon your request, I will
send your bills to another address.)

Right
to Inspect and Copy – You have the right to inspect or obtain a copy
(or both) of PHI in my mental health and billing records used to make
decisions about you for as long as the PHI is maintained in the record. I
may deny your access to PHI under certain circumstances, but in some cases,
you may have this decision reviewed. On
your request, I will discuss with you the details of the request and denial
process.

Right
to Amend – You have the right to request an amendment of PHI for as
long as the PHI is maintained in the record. Imay deny your request.On
your request, Iwill discuss
with you the details of the amendment process.

Right
to an Accounting – You generally have the right to receive an
accounting of disclosures of PHI for which you have neither provided consent
nor authorization (as described in Section III of this Notice).On your request, Iwill
discuss with you the details of the accounting process.

Right
to a Paper Copy – You have the right to obtain a paper copy of the
notice from me upon request, even if you have agreed to receive the notice
electronically.

Psychologists'
Duties:

Iam required by law to maintain the privacy of PHI and to provide you
with a notice of my legal duties and privacy practices with respect to PHI.

Ireserve the right to change the privacy policies and practices
described in this notice. Unless Inotify
you of such changes, however, Iam
required to abide by the terms currently in effect.

If
Irevise my policies and
procedures, Iwill notify you in
writing at your address of record.

V.Complaints

If you are concerned
that Ihave violated your privacy
rights, or you disagree with a decision Imade
about access to your records, you may contact me directly at WCPA.

You may also send a
written complaint to the Secretary of the U.S. Department of Health and Human
Services.I can provide you with the
appropriate address upon request.